Laparoscopic removal of an ingested fish bone from the head of the pancreas: case report and review of literature

Most ingested foreign bodies pass spontaneously through the gastrointestinal tract and only 1% of them can perforate or penetrate the wall of stomach and duodenum and migrate into organs, such as the liver and pancreas. We report herein the case of a 59-year-old woman who presented to the emergency department with epigastric pain and fever. Computed tomography of the abdomen revealed a linear foreign body that perforate the posterior wall of the prepyloric region of the stomach. The foreign body was removed laparoscopically in one piece and was identified as a 3-cm-long fish bone. The patient recovered without complications and was discharged on the 4th postoperative day. Pancreatic foreign body is a rare entity and laparoscopic removal is warranted in majority of cases.


Introduction
Foreign bodies in the pancreas are rare and usually caused by sharp objects, such as fish bones, sewing needles or toothpicks [1]. These objects usually pass through the anus without any complication. In 10-20% of patients endoscopic removal is required, while in 1% of patients surgery is necessary. Fish bone is an ingested foreign body which can perforate through the wall of stomach or duodenum and migrate to other surrounding organs like the pancreas and liver [2].
Many life-threatening complications like pancreatitis, pancreatic abscess and pseudoaneurysm can be occurred, when a foreign body reach pancreas [3]. There are very few reported cases in which an ingested foreign body penetrated the gastrointestinal tract and migrated into the head of the pancreas. We herein report a case of a laparoscopic removal of an ingested fish bone that was embedded into the pancreas.

Patient and observation
A 59-year-old female with hypertension and hyperthyroidism presented to our hospital with fever and epigastric pain for 2 days which was not associated with heartburn, vomiting, melena or haematemesis. On examination, the patient's temperature was 37.4°C, heart rate was 97 beats per minute, blood pressure was 178/91 and respiratory rate was 19 breaths per minute. Her abdomen was soft, without distension and with no evidence of palpable mass.
Her routine blood tests including haemogram, C-reactive protein level, liver and renal function test, serum amylase and lipase were normal.
Chest and abdominal radiography showed no abnormalities ( Figure   1A formation. An attempt was made by gastroenterologists to remove the foreign body endoscopically. This was unsuccessful because the foreign body was not detected and patient agreed to undergo a surgery. A laparoscopic surgery was performed. During the operation, the greater omentum was separated from the transverse colon and the lesser sac was opened with the help of laparoscopic instrument. A linear foreign body was found between the prepyloric region of the stomach and the pancreatic head ( Figure 2A) and was safely removed from both pancreas and stomach in one piece laparoscopically. The foreign body was identified as a 3-cm-long fish bone ( Figure 2B).
Bleeding was controlled by pressure with a gauge and no suture repair was performed, because the penetrated gastric wall was small and no leak was observed. No drain was placed in the lesser sac. The procedure was total laparoscopic and there was no reason for conversion to an open approach. The patient did not have any postoperative complication and she was mobilized 12hours postoperatively. She was started on oral diet on postoperative day two and was discharged on postoperative day four. She is doing well for 1 year after the surgery.

Discussion
Sharp foreign bodies like fish bone, chicken bone, tooth pick and sewing needle may be ingested accidentally or otherwise [1].  Table 1. In these cases, a fish bone penetrated the stomach [4,5,8,10] or the duodenum [6,7,9]. Open surgical approach was preferred in the 6 of them and only in one case the ingested fish to improve the prognosis of this rare condition. A mortality rate of 10% has been reported because of missed or delayed diagnosis [8].
Since many foreign bodies migrate to the pancreas, a laparoscopic approach may be beneficial over open procedures because it allows the surgeon to approach the lesser sac with minimal manipulation of surrounding tissues while being aided by optimal magnification and illumination [2]. For diagnosed abdominal foreign body extraction, laparoscopic approach should be preferred especially in stable nonacute patients, because of its advantages of less postoperative pain, lower incidence of wound infection, and minimal surgical stress [3]. In the present case, we first attempted to remove the foreign body endoscopically, but failed because it was not detected.
Our patient underwent a laparoscopic removal of an ingested fish bone and recovered without complications.

Conclusion
Cases with foreign bodies in the pancreas are very rare and usually

Competing interests
The authors declare no competing interests.

Authors' contributions
All authors have read and agreed to the final version of this manuscript.